Lecture 2 Flashcards by Katherine Nadelberg

Search pattern for x-ray

Alignment
Bone density
Cartilage space
Soft tissue

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3 components of alignment in x-ray search pattern

Skeletal architecture
Contour
Adjacent bones

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2 components of bone density in x-ray search pattern

General & local changes

2. Trabecular structure

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3 structures of cartilage space in x-ray search pattern

Joint space
Subchondral bone
Epiphyseal plates

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4 components of soft tissue structures in search pattern for x-ray

Muscles
Fat pads & lines
Joint capsules
periosteum

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Alignment:

What is “normal” for skeletal architecture

Normal size

Normal number

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Alignment:

What is “abnormal” for skeletal architecture

Absent bones
Extra bones
Deformities
Fractures

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Alignment:

What is “normal” for contour of bone?

Outline smooth and continuous

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Alignment:

What is “abnormal” for contour of bone?

Spurs
Avulsions
Impaction

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Alignment:

What is “normal” for alignment of adjacent bone?

Normal joint articulation

2. Normal spatial relationships

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Alignment:

What is “abnormal” for alignment of adjacent bone?

Joint subluxations
Joint dislocation
Fracture
Past surgeries

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Where are bone spurs often found?

Heel

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How many growth plates do we initially have? How old are individuals with growth plates that are still forming?

7 growth plates

Ages 7-12

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Bone density:

What is “normal” with general density?

Sufficient contrast between tissue (cortical brighter and more opaque than medullary area)
Sufficient contrast between cancellous and cortical bone

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Bone density:

What is “abnormal” with general density?

Poor contrast between bone and soft tissue

2. Loss of cortical margin

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Bone density:

What is “normal” with trabecular structure?

Normal…

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Bone density:

What is “abnormal” with trabecular structure?

Altered trabecular appearance

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Bone density:

What is “normal” with local density changes?

Sclerosis in weight bearing stress areas

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Bone density:

What is “abnormal” with local density changes?

Excessive sclerosis- opaque
Reactive sclerosis
Osteophytes

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What is sclerosis?

Thickening of the bone, more opaque

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Cortical margin of the bone is more ______

Opaque

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Trabecular lines through the bone can be seen with this condition

Osteoporosis

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What is a “bone island?”

Sclerotic area- isolated in the bone… normal changes, just isolated to one spot

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View of a stress fracture- ______ is visible, edge of bone not smooth

Lucency

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With this condition, the cortical area is stripped of bone in the tibia/fibula

Hyperthyroidism

How can you tell if person has OA or RA in the hands?

RA typically B/L

Cartilage space: | What is "normal" with joint space?

Well preserved

Cartilage space: | What is "abnormal" with joint space?

Decreased or altered

Cartilage space: | What is "normal" with subchondral bone?

Smooth surface

Cartilage space: | What is "abnormal" with subchondral bone?

1. Excessive sclerosis | 2. Erosion

Cartilage space: | What is "normal" with epiphyseal plates?

Normal based on skeletal age

Cartilage space: | What is "abnormal" with epiphyseal plates?

Asymmetries

How can you tell if x-ray is adult hand or pediatric?

Pediatric has more space in the joints, epiphyseal plates visible

Need to consider the ____ of the individual when viewing x-ray

age

what happens in degenerative disc disease?

1. Bone changes between the 2 end plates 2. Discs over time degenerate- position of disc in relation to vertebrae changes 3. Traction spurs may develop to support protruded disc

Soft tissue: | What is "normal" with muscles?

Normal size

Soft tissue: | What is "abnormal" with muscles?

1. Swelling | 2. Wasting

Soft tissue: | What is "normal" with fat pads & lines?

1. Parallel to bone | 2. Parallel to muscle

Soft tissue: | What is "abnormal" with fat pads & lines?

Displacement, elevation or blurring = swelling

Soft tissue: | What is "normal" with joint capsules?

Non-distinct (not projecting more than it would normally

Soft tissue: | What is "abnormal" with joint capsules?

Distended

Soft tissue: | What is "normal" with periosteum?

1. Non-distinct | 2. Reaction in fracture healing

Soft tissue: | What is "abnormal" with periosteum?

Periosteal reactions

Soft tissue: | What is "normal" with miscellaneous?

Soft tissue normally gray

Soft tissue: | What is "abnormal" with miscellaneous?

Radiolucent or radiopaque

How does a fat pad appear on a CT?

Lucent area on CT

What is it called when the fat pad becomes inflamed/swollen and expands away from bone (becomes visible on CT)

Sail sign

What are the shoulder routine views?

``` Anteroposterior Anteroposterior ER Anteroposterior IR Lateral AC joint ```

What is a hill sacks lesion?

Deformity of humeral head when there is deformity- creates what looks like divot across where bony tissue has been deformed

What is a Bankhart fracture?

Occurs in glenoid area- lucency along edge where rim of glenoid is fractured

What is a bankhart lesion?

Labrum tears away from rim

What are the elbow routine views?

Anteroposterior Lateral Oblique

What do you want to see from the lateral view of the elbow (indicates good view)

Figure 8 | Fat pad visible

What are the hand routine views?

Posteroanterior Oblique Lateral

What is a fracture to the 5th metacarpal called?

Boxer's fx

What are the wrist routine views?

Posteroanterior Oblique Lateral

What is seen on an x-ray with arthritis of the wrist?

Sclerosis between the joints

Why does the scaphoid fracture most easily?

Has least movement of all the carpal bones

Hip/pelvis routine views?

Anteroposterior | Lateral frog leg

What do trabecular lines indicate?

Lucency surrounded by sclerosis suggests it may have started as stress fracture (already attempting to develop more bone in that area)

What does it mean when lucency forms along prosthesis?

Prosthesis is loosening

Knee routine views?

Anteroposterior Lateral Tunnel Tangential

Tangential view of patella aka

Sunrise view

Foot routine views?

Anteroposterior Lateral Oblique

views of cervical spine?

``` Anteroposterior upper Anteroposterior lower Lateral Oblique Stress views ```

What is the difference between a lateral and oblique view of the cervical spine?

Oblique shows foramen better- opening more visible in oblique Lateral shows facet joint better

What is a stress view of the cervical spine?

In flexion/extension

Thoracic spine views?

Anteroposterior Lateral Oblique

Lumbar spine views?

``` Anteroposterior Lateral Oblique L5-S1 S1 AP ```

What is the best view to see the "Scotty dog" in the lumbar spine?

Oblique- can see foramina

Deep lucency in the vertebrae indicates _____

Osteoporosis- loss of bone density

Most common mechanism of injury for shoulder

Falls (FOOSH)

In elderly osteoporotic female, falls typically result in ________ (relating to shoulder)

Surgical neck of humerus fx

In younger adults, fractures of _______ may be associated with dislocation of _______ or injury to _______ muscles (SHOULDER RELATED)

Humeral head GH joint Rotator cuff

95% of shoulder dislocations are ______

Shoulder separation refers to ligamentous sprain or rupture at the _______

AC joint

(SHOULDER) Radiographs adequately demonstrate ____, ____, _____ as well as nontraumatic disorders such as various arthritides

Fractures Dislocations Calcific tendinitis

(SHOULDER) CT provides optimal visualization of ________, especially in characterizing _________ of humeral head

Complex fractures | Fracture/dislocation

(SHOULDER) MRI used to evaluate glenoid ______, _____ tears, ______ syndromes, instability, and tendon and ______ abnormalities

Labrum tears Rotator cuff Impingement Bursa

(SHOULDER) Msculoskeletal US equivalent to _____ in evaluation of bursitis, long head of triceps tenosynovitis, and retears of prior surgical rotator cuff repairs. It is superior to ____ in evaluation of rotator cuff tears after _______.

MRI MRI Total shoulder arthroplasty

Most common type of MOI for shoulder injury

Falls (FOOSH)

________ fx of distal humerus is second most common fx of childhood, following fx of _______

Supracondylar | Distal radius

________ fractures make up one-third of all fractures at the elbow

Radial head

______ fractures occur in the elderly as low-energy fxs that result from indirect trauma caused by sudden pull of triceps and brachioradialis muscles

Olecranon

______ are second most common dislocation in adults and most common major joint dislocation in children

Elbow dislocations

4 athletic injuries that occur at the elbow

Osteochondritis dissecans Epicondylitis UCL tear Snapping triceps

Most common MOI to wrist/hand

Fall- FOOSH

In children, the ______ is the most frequently fractured bone anywhere in skeleton

Distal radius

In adults the _____ is the most frequently fractured bone in wrist, followed by ___ and ___

Distal radius Scaphoid Lunate

Tears of _____ seen in sports in which there is repetitive force on a wrist positioned in extension and/or ulnar deviation

TFCC

For unstable AC joint or "shoulder separation," this view is used with this modification

standing AP bilateral views made with and without weights hanging from patient's hands

For assessment of scapula, ____ and ____ views are performed with positioning that removes superimposition of rib cage

AP and lateral

Indications for MRI of shoulder (8)

1. Rotator cuff pathology 2. Long head biceps tendon pathology 3. Glenoid labrum pathology 4. Soft tissue/osseous coracoacromial arch impingement 5. Osteochondral and articular cartilage abnormalities 6. Loose bodies: chondral, osteochondral, or osseous 7. Marro abnormalities: contusions, osteonecrosis, stress fxs 8. Neoplasms or infections of bone, joint, or soft tissue

included in MRI protocol for shoulder are _____ sequences and _____ sequences

Anatomy-defining | Fluid-sensitive

_________: contrast is injected into GH joint prior to MRI exam

MR arthrography

MRI search pattern

``` Alignment/anatomy Bone signal Cartilage EDema Soft tissues ```

What is "alignment" in MRI

Disruptions of soft tissue attachment to bone, congruity of all joint surfaces and potential spaces for compromise

What is "bone signal" in MRI

Marrow edema, stress fx, osteochondral injuries, defining ambiguous fx on xray

What does "cartilage" show on MRI

Assess for abormalities of joint surfaces, labral tears

What does edema show on MRI

Footprint of injury | Images as intermediate signal on anatomy- defining sequences and high signal on fluid sensitive sequences

What do soft tissues show as on MRI

Continuity of muscles/tendons, assess ligaments, capsule

_____ is imaging modality of choice in skeletal conditions when structural or spatial info f bones and joint articulation is needed

Primary indications for CT of shoulder:

``` Severe trauma Alignment and displacement of fx fragments Loose bodies in GH joint Eval of labral/rotator cuff pathology Any condition typically evaluated by MRI ```

CT imaging principles- What colors are different structures

Air = black Fat = gray-black Water (soft tissue) = gray Bone = gray-white

Study of choice for evaluation of soft tissue abnormalities, chondral and osteochondral lesions, radiographically occult bone abnormalities

MRI

Chronic pain persistent that has developed over time in elbow =

Chronic elbow pain

Term "joint mice" refers to looks bodies within a joint, composed of both bone and cartilage, which can arise from several sources in elbow =

Intra-articular osteocartilaginous body

Injury that is "hidden" and cannot be easily detected by radiograph in elbow =

Occult injury

Advanced stage of focal injury to articular cartilage, focal lesion becomes detached from main body of bone in elbow =

Unstable osteochondral injury

Soft tissue tumors at elbow are rare; mass must be distinguished from infection, trauma, inflammatory process ... called a

Soft tissue mass

Lateral ____ or tennis elbow is inflammation of extensor muscle group's origin....... medial ______ or golfer's elbow is inflammation of flexor group's origin

Epicondylitis (lalgia)

Tear refers to MCL/UCL/LCL at elbow

Collateral ligament tear

Bicipitoradial and interosseous bursas around distal biceps tendon can be source of anterior elbow pain if inflamed =

Biceps tendon tearbursitis

Ulnar nerve is vulnerable to trauma from direct blow to cubital tunnel =

Nerve abnormalities

Formation of ectopic bone that forms around major joints following brain injury/over long-bone fxs

Heterotropic ossification

Formation of osteophytes, spurs at joint margins, common in OA

Osteophytosis

Neoplastic process that occurs within bone

Osseous tumor

___ centers of ossification at elbow... | Boys ossify ____ later than girls do

6 | 2

The _______ and abnormal supinator line are highly associated with ______ at the elbow

Positive fat pad sign | Fractures

``` Collateral, radial, annular ligament tears Epicondylitis Distal biceps/triceps tendon tears Osteochondral lesions Intra-articular loose bodies Olecranon/bicipitoradial bursitis Marrow abnormalities Ulnar nerve compression Symptomatic place Neoplasms or infections of bone, joint, soft tissue Abnormalities of proximal forearm interosseous membrane.... ...... ALL INDICATIONS FOR ______ ```

MRI

What anatomy sequence and fluid-sensitive sequence are associated with this orthogonal plane: AXIAL

PD | T2 weighted with fat saturation

What anatomy sequence and fluid-sensitive sequence are associated with orthogonal plane: SAGITTAL

T1 | T2 weighted with fat saturation

What anatomy sequence and fluid-sensitive sequence are associated with orthogonal plane: CORONAL

PD | T2 weighted with inversion recovery

MR arthrography is most often used to assess stability of _____ lesion or identify tears of ______ at elbow

Osteochondral lesion | Collateral ligaments

Indications for CT at elbow (SAALE)

Severe trauma alignment and displacement of fx fragments Any condition evaluated by MRI if MRI is contraindicated Loose bodies in elbow joint Evaluation of osteochondral lesions if MRI is contraindicated

MSUS is considered first line examination and is performed in conjunction with ________ at elbow

Conventional radiography

Pain, swelling, joint instability, presence of mass all warrant use of _______

MSUS

Define tears, tendinosis, calcification Define tears of collateral ligaments discriminating between full and partial tears during dynamic valgus/varus test Eval olecranon and bicipitoradial bursa for burial thickening Eval articular cartilage Assess for loose intra-articular bodies Differentiate complex fluid of effusion from synovitis Assess nerve entrapment Dynamically assess nerve and muscle head ..... indications for use of _____

MSUS at elbow

``` Define tendon abnormalities Define compression neuropathic Define collateral ligament tears Differentiate soft tissue masses Define TFCC tears or degenerative changes .... all seen with ______ ```

MSUS

_____ sufficient to dx phalangeal and metacarpal fractures

Radiograph

Thumb metacarpal fx, gamekeeper's thumb, bennett's fx- all use _____ imaging for dx

Oblique views of radiograph, fluoroscopy, CT

Fx of scaphoid viewed with ____

Radiographs- if non-diagnostic but suspicion for fx is high, can take MRI... CT if MRI unavailable

Osteonecrosis of lunate, Kienbock's disease use ______ for dx

MRI most sensitive to marrow changes

Tears of TFCC use ____ imaging

MRI with dedicated wrist coils and MR arthrography

Femur fx use ____ imaging

Radiographic for dx, CT may be needed for fragment localization

Tibial plateau fx imaging ____

Radiographs, 3D CT, MRI (occult fxs via bone marrow edema)

Osteochondritis dissecans best viewed with _____

Radiographs and MRI

ACL best viewed with ____

Radiograph to rule out avulsion fx, sagittal MRI

Medial meniscus tear use _____ imaging

MRI

DJD use ____ imaging

Radiography

Most frequently injured joint in body in adults by trauma

Ankle

Fractures at ankle can be ___, ___, ____

Unimalleolar, bimalleolar, trimalleolar (posterior rim of tibia is 3rd malleolus)

Bimalleolus fx use ____ imaging

X-ray

Fx at base of 5th metatarsal use ____ imaging

X-ray, MRI for confirming stress fx

Fx of talar neck use ____ imaging

X-ray, CT, or MRI

Tarsal coalition use ___ imaging

X-ray, MRI, CT to determine fibrous or bony coalition

Ankle sprain use ____ imaging

X-ray to rule out avulsion fx, MRI or US to assess tears

Osteomyelitis in foot in patient with DM use ____ imaging

MRI

Oblique view of foot is performed from perspective of _____ degrees between AP and lateral views

____ and ____ define anatomy in MRI, _____ detects abnormal fluid

PD, T1 | T2

``` Severe trauma Complex fractures and dislocations Loose bodies in joint Tarsal coalition Osteochondral lesions Pre-op planning .... use ____ imaging ```

Clinical symptoms that use MSUS for examination (along with conventional xray)

Pain Swelling Joint instability Presence of mass

``` ____ used for Achilles' tendon disorders Tib post disorders ATFL/CFL/Deltoid ligament tears Soft tissue or issues impingement Osteochondral and articular cartilage abnormalities Loose bodies Plantar fasciitis Marrow abnormalities Neoplasms or infections Congenital or developmental conditions ```

MRI